Inquest into the death of RP and DJ
Deceased
RP and DJ
Demographics
male
Date of death
2010-04-24
Finding date
2019-07-04
Cause of death
RP: fatal pressure to the neck; DJ: neck compression
AI-generated summary
Two remand inmates died in separate incidents at the Metropolitan Remand and Reception Centre after being placed with mentally ill cellmates exhibiting acute psychosis. RP died in 2010 from injuries inflicted by cellmate MA, who was suffering untreated schizophrenia with command hallucinations. DJ died in 2012 from injuries inflicted by cellmate BB, who was treatment-resistant, non-compliant with medication, and acutely psychotic. Both deaths were preventable through better mental health screening, risk assessment, information sharing between custodial and health staff, improved medication chart access, and avoiding cell placement of acutely mentally ill inmates with other vulnerable prisoners. Clinical lessons include: acutely psychotic inmates require specialist psychiatric care outside general prison populations; psychotic symptoms (delusions, hallucinations, paranoia) must trigger urgent psychiatric assessment and protective cell placement; medication non-compliance requires escalation; prior mental health records must inform current risk assessments; and custodial staff need better health information to make safer cell placement decisions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Failure to identify acute schizophrenia in MA and BB at intake/screening
- Inadequate risk assessment regarding harm to others from acutely psychotic inmates
- Placement of acutely mentally ill inmates with other vulnerable inmates in two-out cells
- Delayed or absent psychiatric review despite psychotic symptoms
- Non-compliance with medication not adequately monitored or escalated
- Poor information sharing between Justice Health and Corrective Services regarding mental health status
- Insufficient access to medication charts by assessing clinicians
- Pressure to clear remand cells overriding proper mental health assessment
- Inadequate dedicated mental health facilities within prison system
- Psychotic symptoms (delusions, hallucinations, paranoia) not recognized as requiring urgent psychiatric assessment
Coroner's recommendations
- Urgent review of need for assessment cells at MRRC and extent to which lack of access is delaying intake of new inmates
- Consideration given to research into feasibility and clinical benefits of treating all acutely mentally ill inmates in secure health facility rather than general prison population
- Creation of new space for RAIT assessments and mental state examinations as part of building project at MRRC
- Steps taken to ensure inmates' medication charts routinely available to RITs/RAITs and mental health nurses and psychiatrists conducting mental state examinations
- File keeping practices adjusted to ensure discharge summaries from community providers collated and held together in one part of file and moved from closed volumes into new volumes for easy access
- Existing policies governing exchange of information between Justice Health and CSNSW amended to ensure health information relevant to risk of harm to others included on HPNF or other form
- Following amendment to HPNF policies, training implemented for RIT/RAIT staff regarding purpose of HPNF
Full text
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